Client Health Assessment Flashcards

Ankle indentation from pressing disappears within 15 seconds. How should this pitting edema be graded?

Answer: +1 pitting edema

+1 pitting edema: slight indentation (2mm) rebounding within 15 seconds, indicating mild fluid accumulation.

In the PQRSTU pain assessment tool, what does the U assess?

Answer: Understanding of the client about their pain

U = Understanding: what the pain means to the client and their knowledge about it.

In which client is a third heart sound (S3) most clinically significant?

Answer: Adults over age 40 with possible heart failure

S3 in adults over 40 is pathological (ventricular gallop) strongly associated with heart failure and volume overload.

A skin lesion is raised, well-defined, less than 1 cm, and filled with clear fluid. How is it classified?

Answer: Vesicle

A vesicle is small (<1 cm), raised, and filled with clear serous fluid, seen in herpes, varicella, and contact dermatitis.

Fluid intake was 2,800 mL and urine output was 2,200 mL over 24 hours. How should this be interpreted?

Answer: Positive fluid balance of 600 mL

2,800 intake - 2,200 output = +600 mL positive balance, meaning the client retained 600 mL more than excreted.

A client is asked to name the Prime Minister of Canada and the current season. Which cognitive domain is being tested?

Answer: Orientation

Naming current political leaders and the season tests orientation to current events and time.